Here's a roundup of mind-over-money tips from industry experts to help your special investigations unit (SIU) achieve more with less.
1. Put your most aberrant provider on prepayment review
Prepayment claims review prevents overpayments, but it's a costly process limited by staff capacity. Payers can reap rewards, though, by doing this function on a small scale. Consider doing prepayment review of claims from your most aberrant provider to generate dollar-for-dollar savings, advised Alanna Lavelle, director of enterprise investigations at WellPoint, in an interview with FierceHealthPayer: AntiFraud.
2. Leverage, leverage, leverage
Some SIUs can't afford costly analytic solutions; but since most insurers have teams doing data analysis for other purposes, the SIU should leverage that resource if possible, said Ralph J. Carpenter, director of the SIU for Aetna, in an email to FierceHealthPayer: AntiFraud.
Further, raising SIU visibility through all-employee anti-fraud training can multiply sources of fraud intelligence.
To deter identity theft, consider coaching provider office employees to spot and report telltale behaviors of identity thieves who present themselves for care, recommended KellyAnn Bowman, SIU manager for Group Health Cooperative in Seattle, in an interview with FierceHealthPayer: AntiFraud.
And network regularly with colleagues to keep abreast of new fraud schemes that may be headed your way, Bowman advised.
3. Triage cases to maximize efficiency and effectiveness
To focus on issues with strong investigative merit, have a good triaging team in place to distribute high-risk cases. "Weeding out false positives at the front end saves time and wasted investigative efforts," Carpenter said.
4. Diversify staff skills
SIUs should maintain a staff with the skills to process cases independently, Carpenter noted. A well-rounded SIU works more efficiently. If you're in a position to hire or reorganize, consider enriching your team with nurses, medical directors, certified coders, claims specialists, certified pharmacy technicians, accredited healthcare fraud investigators or other diversely-trained professionals.
5. Make the most of applied technology
If your SIU deploys technology to detect, investigate and track potential fraud, perform periodic checks to ensure you're using that resource to its fullest potential, Carpenter recommended.
6. Use ratios
If a state-of-the-art anti-fraud data solution isn't affordable, using ratios can serve as a low-cost means of data analysis to find probable cases, according to Darrell Langlois, vice president of compliance, privacy and fraud at Blue Cross and Blue Shield of Louisiana.
"With any specialty in any fraud scheme, there are four ratios," he told FierceHealthPayer: AntiFraud. "By simply putting two numbers one over the other, generating a ratio, and then matching those numbers provider by provider, you can determine who presents themselves as vulnerable to committing fraud."
The ratios are average dollars paid per patient, average visits per patient, average dollars paid per medical procedure and average medical procedures per visit.